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Page 8 of 13 Gharagozloo. Mini-invasive Surg 2020;4:8 I http://dx.doi.org/10.20517/2574-1225.2019.62

Figure 2. Comparison of cryoanalgesia with conventional pain control techniques utilizing Likert Pain Scores. Although the level of the
pain is significant, cryoanalgesia is more effective than conventional pain control techniques in controlling pain on Days 1, 14, and 30

catheter. The blocks generally last 18-24 h and are very effective and considered by some equivalent to an
[24]
epidural in the first 24 h . A major shortcoming of this technique is the variability of catheter or block
placement by different practitioners, the extra time required in the operating room, and the inconsistent
results from errors in catheter placement.

Liposomal bupivacaine
Standard bupivacaine maintains local anesthetic effects for approximately 18 h. Liposomal bupivacaine
(Exparel) has prolonged local anesthetic effect for up to 72 h. Liposomal bupivacaine is administered
using either a transcutaneous or a intrathoracic technique. Liposomal bupivacaine is approved for local
administration in surgical incisions; however, many thoracic surgeons are using this medication for
subpleural paravertebral blocks in an off-label application. Using this technique, pain relief has been shown
to be better than shorter-acting agents and similar to thoracic epidural [24,25] . In addition, studies have shown
decreased postoperative narcotic administration, shorter hospital stays, and better pain scores versus
thoracic epidural analgesia [26-29] .

Subpleural infusion of local anesthetic
Presently, most robotic surgeons begin the procedure with infiltration of the intercostal nerve with local
anesthetic prior to the conduct of the operation. Other surgeons use local infiltration of the intercostals
at the end of the procedure as their preferred method of local pain control. One shortcoming of this
technique is that the local pain control is short lived and the effect of the local anesthetic quickly wears off.

On the other hand, multiple studies have shown that the continuous infusion of local anesthetic through
[30]
a catheter placed in an extra pleural tunnel overlying the intercostal nerves to be safe and efficacious .
The advantage of this technique is prolonged local pain control. Some investigators have reported
placing the catheter in an extrapleural pocket, while others have placed them close to the heads of the
[30]
ribs in the paravertebral space . Various types of catheters have been used. Randomized studies have
demonstrated better pain relief, better pulmonary function, lower pulmonary complications, and lower
use of narcotics with the use of extrapleural infusion catheters [31-34] . Studies are bearing out the efficacy of
[33]
subpleural infusion of local anesthetic in the acute setting. Taylor et al. specifically studied the use of this
technique in minimally invasive surgery and found it to be an effective form of analgesia and to decrease
[34]
narcotic requirements postoperatively. In addition, Concha et al. studied the use of intercostal nerve
blockade combined with IV PCA compared to epidural analgesia and found little statistical significance
between the two groups. Detterbeck reviewed studies on extrapleural catheter use in patients undergoing